Membership Heeren XVII

Registration form membership Heeren XVII
Name

PrefixFirst NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (+00) 0 00 00 00 00 .
Date of birth

DayMonthYear
Date
Address room (Wageningen or surroundings)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address (home/parents)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Wur-mail
Please enter your WUR e-mail address
Private email
e.g. @gmail or @hotmail
Bank account number (IBAN)
Ex: NL12 ABNA 1234 1234 12
Signature agreement preauthorized debit (for the payment of certain activities, contribution of articles we usepreauthorized debit)
Date

DayMonthYear
Date of signature
Bachelor or Master
Registration number WUR
Signature agreement processing personal data. The privacy guidelines can be found at: heeren17.nl/vereniging/privacyverklaring
I would like to participate with the buddy system (with te buddy system you will be coupled to a biosystems engineering student who can guide you to get started finding you path studying in Wageningen)
If any of the above questions failed, you can fill the question and answer in here
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Registration form membership Heeren XVII